Public Health in Oregon

1. Public Health in Oregon Presentation by Morgan D. Cowling & Lila Wickham CLHO Retreat September 18th, 2013

2. Highlights: • What is Public health? • Oregon State-local System of Public Health • Local Authority and Responsibilities • Local Public Health Authority • Required services as authority • Public Health Funding Sources • About CLHO • Moving Forward – Public Health Issues, Opportunities and Challenges

3. What is Public Health? • Public Health is focused on the population NOT the individual • Public health is what we, as a society, do collectively, to assure the conditions in which people can be healthy.Institute of Medicine, 1988: The Future of Public Health

4. The community is our client • Health Care Providers diagnose & treat individual patients • Public health asks: what is the impact to health & how can this be prevented? • Assesses the larger picture, monitor trends, identify risk factors • Convenes partners to listen, teach, & develop prevention action plans • Develops prevention policies & advocates for change • Evaluates the impact of the strategies & interventions & disseminates the results

5. State-Local System of Public Health • Public Health systems are primarily governmental • Public health in Oregon is DECENTRALIZED • Centers for Disease Control and Prevention is the lead federal agency • Oregon Health Authority – state agency • 34 local health departments across Oregon (one district – North Central Public Health District)

6. Oregon Health Authority – Org Chart

7. Local Authority and Responsibility • Boards of County Commissioners are the Local Public Health Authority according to ORS 431.375 • The Legislative Assembly of the State of Oregon finds that each citizen of this state is entitled to basic public health services which promote and preserve the health of the people of Oregon. To provide for basic public health services the state, in partnership with county governments, shall maintain and improve public health services through county or district administered public health programs. • County Governments or health districts established under ORS 431.414 are the local public health authority responsible for management of local public health services unless the county contracts with private persons or an agency to act as the local public health authority or the county relinquishes authority to the state. If authority is relinquished, the state may then contract with private persons or an agency or perform the services.

8. Duties/Requirements of LPHA • Enforce public health rules/laws ORS 431.416 – The local public health authority or health district shall: • Administer and enforce the rules of the local public health authority or the health district and public health laws and rules of the Oregon Health Authority; • Assure activities necessary for the preservation of health or prevention of disease in the area under its jurisdiction as provided in the annual plan of the authority or district are performed.

9. Required Services of LPHA • ORS 431.416 (2) continued… • These activities shall include but not be limited to: • Epidemiology and control of preventable diseases and disorders • Parent and child health services, including family planning clinics as described in ORS 435.205 • Collection and reporting of health statistics • Health information and referral services; and • Environmental Health Services

10. Minimum Local Public Health Services in Rule (under ORS 431.416) • Communicable Disease Investigation and Control • Tuberculosis case management • Immunizations • Tobacco Prevention • Emergency Preparedness • Maternal and child health services • Family Planning • Women, Infants, and Children services • Vital Records • Environmental Health Services

11. Other statutory requirements: • ORS 431.418 – LPHA must hire a public health administrator (standards for education set in the minimum standards) • ORS 431.418 – If the public health administrator is not a physician the LPHA must employ or contract with a health officer • ORS 431.121 – Local public health administrator may issue an emergency order for isolation and quarantine

12. Statutory requirements cont • ORS 431.440 – public health administrators have police powers – “public health administrators shall possess the powers of constables or other peace officers in all matters pertaining to the public health” • 431.530 – in an public health emergency – “the local public health administrator may take any action which the OHA or its director could have taken, if an emergency endangering the public health occurs within the jurisdiction..”

13. Funding from State Financial Assistance Agreements

14. Local health department revenue sources -2011-13 Adopted Budgets

15. Conference of Local Health Officials • Shared governance between the local health officials and the state public health division • ORS 431.330 Conference of Local Health Officials is created. (1) The Conference shall consist of all local health officers and public health administrators, appointed pursuant to ORS 431.418 and such other local health personnel as may be included by the rules of the conference.

16. Conference of Local Health Officials Scope and Duties: • Make Recommendations on funding distribution formulas • Make recommendations on program elements • Set minimum standards for local public health • Minimum standards including education requirements for public health administrators, registered environmental health specialists, health officers, and public health nursing supervisors

17. CLHO Funding Formula • ORS 431.380 – • From funds available to the Oregon Health Authority for local public health purposes, regardless of the source, the Authority shall provide payments to the local public health authority on a per capita or other equitable formula basis to be used for public health services. Funding formulas shall be determined by the department with the concurrence of the Conference of Local Health Officials.

18. Conference Structure • The Conference functions through committees: • CLHO Communicable Disease • CLHO Healthy Families • CLHO Healthy Communities • CLHO Information Management • CLHO Healthy Structure (internal public health structure) • CLHO Health System Transformation (new committee) • CLHO Preparedness • Recommendations from Committees on policy or budget issues must go to the full CLHO Board for discussion and approval.

19. Coalition of Local Health Officials (the other CLHO) • Workforce development and technical assistance and training • Advocacy and representation before boards, commissions and the legislature • Support for public health administrators • Work to generate funding opportunities for the whole system of public health through the legislature and private funding sources

20. Coalition’s 2013 Legislative Agenda • Endorsement of the Tobacco Master Settlement Agreement Proposal to invest $120 million into health and prevention • Support the Governor’s proposal of the Health System Transformation Fund ($30 million) • Increase funding to the public health budget • Support connections between early learning and health to support healthy children.

21. Emerging Public Health Issues, Opportunities and Challenges • National movement toward the accreditation of local health departments • Rise and cost of chronic diseases • Current Fiscal landscape – federal, state and local • State Health System Transformation

22. Accreditation of Local Health Departments • What is Accreditation - Recognition for a health department to meet nationally recognized public health standards that assure high quality services, accountability and efficiency. • Commissioners, as the Local Public Health Authority, play an important role in the Accreditation process – site visit will require engagement by Commissioners/ Board of Health • 4 major areas of readiness: Community Health Assessment, Community Health Improvement Plan, Strategic Plan and continuous quality improvement

23. Why be an accredited local health department? • Training & TA resources available to health departments now • Potential grant opportunities • Potential to become more competitive applicant for other funding opportunities • Potential for a stronger voice at the table in CCO conversations or with other partners • Defines role of Public Health as all these transitions occur • Focus on efficiency and quality improvement essential in current economic environment

24. Local Accreditation Readiness 2012 Involved in discussions about accreditation; seeking technical assistance & information when possible COLUMBIA CLATSOP HOOD RIVER MULTNOMAH SHERMAN WASHINGTON WALLOWA UMATILLA TILLAMOOK MORROW Started actively progressing toward accreditation YAMHILL CLACKAMAS GILLIAM UNION WASCO POLK MARION WHEELER LINCOLN JEFFERSON BAKER GRANT Working on or have completed the prerequisites for Accreditation LINN BENTON CROOK LANE DESCHUTES Submitted Statement of Intent or Application for Accreditation COOS DOUGLAS MALHEUR LAKE HARNEY KLAMATH Local Health Departments working on formal QI projects CURRY JACKSON JOSEPHINE Current as of December 2012 based on status updates and surveys conducted by CLHO. Please Note: this may not represent all health department progress toward accreditation as accreditation readiness evolves quickly.

25. Current Fiscal Landscape • Of the pass thru funding from the Public Health Division the majority is federal. Federal funds are very categorical and hard to invest in specific local needs. • Sequestration has put some questions around the level of funding moving forward especially for Public Health Preparedness, Women, Infants and Children supplemental nutrition, MCH Block grants and other federal funding streams • Local funds are essential to the financial viability of local public health but are declining with the loss of Timber Payments • State has replaced State General funds for public health with more volatile fee

26. Health System Transformation • HB 3650 (2011) and SB 1580 (2012) created Oregon’s system of Health System Transformation – Coordinated Care Organizations (CCOs) • The bills are largely silent on the relationship between governmental local public health and CCOs • HB 3650 requires agreements between local public health and CCOs for “point of contact” services including immunizations, communicable disease, sexually transmitted infections etc • SB 1580 defines the duties of the Community Advisory Committee to advocate for preventative care and oversee a Community Health Assessment and Community Health Improvement Plan • This is a great place for collaboration between local public health and CCOs • SB 1580 also allows for the sharing of protected public health information with public health entities for public health oversight purposes

27. Health System Transformation cont. • Public health interventions can help CCOs meet their metrics and outcomes • Public health and CCO partnerships are continuing to develop. Here are a few examples: • Community Advisory Council staff support by LHD • New models of care for maternal and child health for CCO patients • Joint Community Health Assessments focused on larger population health • Tobacco prevention expertise to medicaid population • CCOs support of local health department nurses, epidemiologists and prevention specialists

28. Conclusions: Public Health landscape is changing: • Accreditation is currently voluntary but including opportunities to improve efficiencies • Less need for public health to provide clinical services since insurance coverage required for all by 2014. BUT, not everyone will be covered. • Rise in chronic diseases are identified but there are no stable funding sources to work to address community prevention of chronic diseases. • State Medicaid reform will have an impact on public health and we will have to engage locally with health care partners • Interest from legislators and Oregon Health Authority in moving to a regional public health system

29. Questions?